x = a radiograph image must be included r = a report must ... · - dentures and partials date of...

1

x = a radiograph image must be included

r = a report must be included

fx = a pre and post operative

radiograph image must be included

* = apply only under orthodontic

benefits

GP = GENERAL POLICES

D0100 - D0999 I. DIAGNOSTIC

NOTE: Completion date or date procedure must be billed to Delta

Dental of PR, Inc. is:

- Dentures and partials date of insertion or delivery.

- Crowns and fixed bridges day of cementation.

- Endodontic and periodontal treatment the completion date of

the procedure.

Clinical oral examinations

GP - Infection control and tray or tray preparation are included in

the fee for the dental services provided.

GP - Appliances, procedures or restorations to correct congenital

or developmental malformation are not covered.

GP - The time limitation for examinations is established by the

contract. Any combination of D0150, D0120 or D0140 count

toward the contract limitations.

GP - Oral examinations D0150 and D0120 include examination of

all hard and soft tissue of the cavity including periodontal

charging and oral cancer examination.

GP - The fee for consultation, diagnosis and treatment planning is

part of the fee for the examination and/or diagnostic procedure (s).

2

D0120 periodic oral evaluation - established patient

Periodic oral evaluations are paid as periodic oral examinations,

once every 6 month.

D0140 limited oral evaluation - problem focused

Limited oral evaluation - problem focused is paid as an emergency

examination and is paid once in a 12 month period.

D0150 comprehensive oral evaluation - new or established patient

Comprehensive oral evaluation are paid as initial oral examination

for the first encounter with the dentist/ dental office and

subsequent submissions are paid as periodic oral examinations

00120, once every 6 month.

D0160 detailed and extensive oral evaluation - problem focused, by report

For special consultation only and limited to one in a 12 month

period. Paid only to specialist, (Endodontics, Periodontics, Oral

Surgeons and Orthodontics).

Radiographs

GP – Diagnostic services such as radiographs must be necessary

and done in connection with covered services. Connection and/ or

need not evident from information submitted.

GP – Non- diagnostic radiographs are not payable. Determination

by dentist consultant review.

GP – The time limitation for radiographs is established by the

contract but usually allows 1 set of bitewing x-rays in a 6 month

period or a full mouth series or panorex in a 3 year period.

Additional x-rays are optional services and may be charge to the

patient.

GP - individually listed radiographs are considered a complete

series if the fee equals or exceeds the fee for a complete series.

3

D0210 intraoral - complete series of radiographic images

An intraoral complete series consist of all necessary periapicals

and bitewings. Time limitation of 36 months.

D0220 intraoral - periapical first radiographic image

D0230 intraoral - periapical each additional radiographic image

Routine working and final treatment radiographs are part of the

complete treatment procedure and not a separate benefit.

The time limitation for radiographs is established by contract, but

preferably should be limited to no more than 6 as a combination of

periapicals and bitewings in a one year period.

D0240 intraoral - occlusal radiographic image

D0250 extraoral - first radiographic image

D0260 extraoral - each additional radiographic image

D0270 bitewing - single radiographic image

D0272 bitewings - two radiographic images

bitewings are limited to once in a 6 month period.

D0274 bitewings - four radiographic images

Limited to once in a 12 month period

D0290 posterior-anterior or lateral skull and facial bone survey

radiographic image

Not covered

Only with ortho covered benefit

D0310 sialography

Not covered

4

D0320 temporomandibular joint arthrogram, including injection

Not covered

D0321 other temporomandibular joint radiographic images, by report

Not covered

D0322 tomographic survey

Not covered

D0330 panoramic radiographic image

Time limitations of 36 months.

* D0340 cephalometric radiographic image

Cephalometric film is a covered benefit once in a lifetime only for

orthodontic treatment in connection with orthodontic benefits.

* D0350 2D oral/facial photographic image obtained

intra-orally or extra-orally

Diagnostic photographs are only covered in connection with

orthodontic benefit, once in a lifetime.

Test and laboratory examinations

D0415 collection of microorganisms for culture and sensitivity

Collection of microorganisms for determination of pathologic

agents are not a covered.

D0425 caries susceptibility test.

Not covered

D0460 pulp vitality test

D0470 diagnostic casts

Diagnostic casts are payable only once per case in connection with

orthodontic benefit. Casts taken during or after treatment are

included in the fee for orthodontic services. Once in a lifetime.

5

D0502 other oral pathology procedures, by report.

Not covered

r D0999 unspecified diagnostic procedure, by report

D1000 - D1999 II. PREVENTIVE

Dental Prophylaxis

GP - A prophylaxis done in the same date as a periodontal

prophylaxis, curettage, scaling or root planning is considered to be

part of and included in those procedures.

GP - The time limitation for prophylaxis is established by contract.

Additional prophylaxis are optional and may be charged to the

patient. 04910 is counted toward the contract limitation for

prophylaxis.

GP - A difficult prophylaxis can be given special consideration

and an additional fee can be paid. A difficult prophylaxis will be

limited to once in a lifetime.

D1110 prophylaxis - adult

A person age 12 and older is provided a prophylaxis adult.

D1120 prophylaxis - child

A person under the age 12 is provided a prophylaxis child

D1206 topical application of fluoride varnish

D1208 topical application of fluoride – excluding varnish

Prophylaxis not included - child under 19.

Other preventive services

GP - Plaque control, tobacco counseling for the control of dental

disease, oral hygiene and dietary instructions are optional benefits.

If performed, these services should be done with the agreement of

the patient to assume the cost.

6

D1310 nutritional counseling for control of dental disease

Not covered

D1320 tobacco counseling for the control and prevention of oral disease

Not covered

D1330 oral hygiene instructions

Not covered

D1351 sealant - per tooth

Sealants are payable once per tooth on the occlusal surface of

permanent molars and bicuspids to patients under 14. The teeth

must be free from caries and restorations on the occlusal surface.

The fee for sealants completed on the same date of service and on

the same tooth as a restoration is included in the fee for the

restoration.

No other restoration will be covered within 24 months after a

sealants is placed.

Sealant-per tooth is limited to one benefit per tooth per lifetime.

Space maintenance (passive appliances)

GP - Space maintainers done in connection with orthodontic

treatment are included in the fee for orthodontic treatment.

GP - Repair or replacement of a space maintainer is not covered

GP - Replacement of a space maintainer could be a benefit if

additional extractions are done or to accommodate growth.

GP - Only covered on patients under 14.

GP - Space maintainer for missing primary anterior teeth or

missing permanent teeth are not covered benefits.

GP - Space maintainers fees include all teeth, clasp and rest;

however, this is only applicable to removable space maintainers.

7

xD1510 space maintainer - fixed - unilateral

xD1515 space maintainer - fixed - bilateral

xD1520 space maintainer - removable - unilateral

xD1525 space maintainer - removable - bilateral

D1550 re-cement or re-bond space maintainer

Re - cementation or re- bond of a space maintainer by the same

dentist/office within 6 months is covered in the fee for the space

maintainer.

D1555 removal of fixed space maintainer.

Not covered

D2000 - D2999 III. RESTORATIVE

GP - The fee for a restoration includes services such as, but is not

limited to, slots, preparations, adhesives, etching, liners, bases,

pulp caps, local anesthesia, polishing, occlusal adjustment, caries

removal.

GP - Payment is made for restoring a surface only once within 24

month regardless of the number or combination of restorations

placed. Benefits may be allowed if done by another dental office.

The definition of the same Dentist includes providers in the same

dental office.

GP - Posterior restorations involving the proximal and occlusal

surfaces are considered one restoration for payment purposes.

D2140 amalgam - one surface, primary or permanent

D2150 amalgam - two surfaces, primary or permanent

D2160 amalgam - three surfaces, primary or permanent

D2161 amalgam - four or more surfaces, primary or permanent

Resin - Based Composite Restorations - Direct

GP - In the event an anterior proximal restoration involves a

significant portion of the labial or lingual surface, it may be

reported as 02331 or 02332, as appropriate.

GP - Preventive resin restorations are considered sealants for

payment purposes.

8

GP - 2335 Involves four surfaces including incisal angle.

Resin restorations anterior

D2330 resin - based composite - one surface, anterior

D2331 resin - based composite - two surfaces, anterior

D2332 resin - based composite - three surfaces, anterior

D2335 resin - based composite - four or more surfaces or involving incisal

angle (anterior)

Resin restorations posterior

D2391 resin - based composite - one surface, posterior

D2392 resin - based composite - two surfaces, posterior

D2393 resin - based composite - three surfaces, posterior

D2394 resin - based composite - four or more surfaces, posterior

Procedure codes 02391 through 02394, resin restorations on

posterior teeth are not a covered benefit. The buccal surfaces of

bicuspids will be paid as a 2330 composite restoration. Any other

composite restoration will be paid as an Amalgam restoration. Any

additional fee is the patient’s responsibility.

Gold foil restorations

GP - For inlay restorations, composite onlays and porcelain or

ceramic substrate onlays, an optional benefit will be allowed for an

amalgam and resin restorations. The additional fee is the patient’s

responsibility.

D2410 gold foil - one surface

D2420 gold foil - two surfaces

D2430 gold foil - three surfaces

Inlay / onlay restorations

GP - For inlay restorations, composite onlays and porcelain or

ceramic substrate onlays, an optional benefit will be allowed for an

amalgam or resin restoration, according to the policies for

amalgam and resin restorations. The additional fee will be the

patient’s responsibility.

D2510 inlay - metallic - one surface

D2520 inlay - metallic - two surfaces

D2530 inlay - metallic - three or more surfaces

9

The criteria for approval for Onlay - per tooth are the same as the

criteria for approval for cast crowns.

Cast restorations include all models, temporaries and other

associated procedures.

D2542 onlay - metallic-two surfaces

D2543 onlay - metallic - three surfaces

D2444 onlay - metallic - four or more surfaces

D2610 inlay - porcelain/ceramic - one surface

D2620 inlay - porcelain/ceramic - two surfaces

D2630 inlay - porcelain/ceramic - three or more surfaces

D2642 onlay - porcelain/ceramic - two surfaces

D2643 onlay - porcelain/ceramic - three surfaces

D2644 onlay - porcelain/ceramic - four or more surfaces

D2650 inlay - resin-based composite - one surface

D2651 inlay - resin-based composite - two surfaces

D2652 inlay - resin-based composite - three or more surfaces

D2662 onlay - resin-based composite - two surfaces

D2663 onlay - resin-based composite - three surfaces

D2664 onlay - resin-based composite - four or more surfaces

Crowns - single restoration only

GP - Crowns and cast restorations are considered to be an optional

benefit unless the tooth is damaged by decay or fracture to the

point that it cannot be restored by an amalgam or resin restoration.

GP - Crowns are subject to 5 years limitation for replacement

GP - Tooth preparation, temporary restorations, cement bases,

impressions, crown buildups, occlusal adjustment and local

anesthesia are considered to be included in the fee for a crown

restoration.

GP - Ceramic substrate/porcelain or cast metal crowns are not a

benefit for children under 12 years of age.

GP - Crowns for altering occlusion, improving the occlusal plane,

involving vertical dimension, replacing tooth structure lost by

attrition, erosion and abrasion (wear) or periodontal splinting are

not covered

10

GP - Porcelain fused to metal crowns are not a covered benefit on

molars. An allowance will be made for the appropriate full cast

crown, and the patient is responsible for any additional cost.

r,x D2710 crown - resin - based composite (indirect)

r,x D2720 crown - resin with high noble metal

r,x D2721 crown - resin with predominantly base metal

r,x D2722 crown - resin with noble metal

r,x D2740 crown - porcelain / ceramic substrate

r,x D2750 crown - porcelain fused to high noble metal

r,x D2751 crown - porcelain fused to predominantly base metal

r,x D2752 crown - porcelain fused to noble metal

r,x D2790 crown - full cast high noble metal

r,x D2791 crown - full cast predominantly base metal

r,x D2792 crown - full cast noble metal

The noble metal classification system has been adopted as a more

precise method of reporting various alloys used in dentistry. The

alloys are defined on the bases of the percentage of noble metal

content: high noble- Au, Pd and/or Pt> 60% (with at least 40%

Au); noble- Au, Pd and/or Pt> 25%; and predominantly base – Au,

Pd and/or Pt> 25%.

Other restorative services

D2910 re-cement or re-bond inlay, onlay, veneer or partial coverage

restoration

D2920 re-cement or re-bond crown

Re - cementation by the same dental office of covered restorations

within 6 months of initial placement is considered part of the fee

for the original procedure.

GP - Stainless steel crowns and/or resin crowns are not payable as

a temporary procedure, or to correct congenital or developmental

malformations.

D2930 prefabricated stainless steel crown-primary tooth.

(children under 14 only)

Replacement of a stainless steel crown by the same dentist/dental

office within 24 months is included in the initial crown placement.

11

x D2931 prefabricated stainless steel crown-permanent tooth

(children under 14 only)

Replacement of a stainless steel crown by the same dentist/dental

office within 5 years is included in the initial crown placement.

x D2932 prefabricated resin crown

A prefabricated resin crown is a benefit only on anterior primary

teeth. (children under 14 only)

x D2933 prefabricated stainless steel crown with resin window.

A prefabricated stainless steel crown with resin window is a

benefit only on anterior primary teeth. (children under 14 only)

r D2940 protective restoration

A sedative filling includes the removal of caries and the placement

of the temporary cement. Limited to once per tooth in a 24 month

period. Pulp cap or indirect pulp cap on the same tooth is

considered a duplication of services.

r,x D2950 core buildup, including any pins when required

Substructures are only a benefit when necessary to retain a cast

restoration due to extensive loss of tooth structure from caries or

fracture and are subject to the same time limitations as cast

restorations.

Substructures are only a benefit when followed by a cast

restoration.

D2951 pin retention - per tooth, in addition to restoration

Pin retention is a benefit once per tooth when necessary and in

conjuction with a three or more surface or incisal angle restoration

on a permanent tooth when completed at the same appointment,

limited to 4 pins per tooth. Slots are considered part of the

preparation and are not paid as a separate service. As defined, this

service includes the post and core (build-up).

x D2952 post and core in addition to crown, indirectly fabricated

12

A cast post and core in addition to crown is payable only on an

endodontically treated tooth. And limited to once in a 5 years

period.

x D2954 prefabricated post and core in addition to crown

A prefabricated post and core in addition to crown is payable only

on an endodontically treated tooth. Prefabricated post and cores are

not a covered benefit on teeth with crowns that will not be replaced

after endodontic therapy. Limited to once in a 5 years period.

D2955 post removal

(not in conjunction with endodontic therapy)

Not covered it is considered part of the fee for new post.

D2960 labial veneer (resin laminate) - chairside

D2961 labial veneer (resin laminate) - laboratory

D2962 labial veneer (porcelain laminate) - laboratory

Laminates are not covered. An allowance will be made for a resin

restoration and the patient is responsible for any additional cost.

D2970 temporary crown (fracture tooth)

Not covered

r D2980 crown repair necessitated by restorative material failure

Benefit for a crown repair is limited to one in 24 months on the

same tooth. Any additional fee for repairs is the patient’s

responsibility.

r D2999 unspecified restorative procedure, by report

D3000 - D3999 IV. ENDODONTICS

Pulp Capping

GP - Allowance for indirect pulp cap includes the sedative

restoration.

GP - Direct or indirect pulp caps provided on the same date as the

final restoration are considered part of a single complete

restorative procedure.

GP - Limited to once per tooth in a 24 month period.

13

x D3110 pulp cap - direct (excluding final restoration)

The fee for pulp cap- direct is included in the fee for the

restoration.

x D3120 pulp cap - indirect (excluding final restoration)

The fee for a pulp cap-indirect is included in the fee for the

restoration.

Pulpotomy

x D3220 therapeutic pulpotomy (excluding final restoration) - removal of

pulp coronal to the dentinocemental junction and application of

medicament

Therapeutic pulpotomy is limited to primary teeth.

The fee for a pulpotomy on a permanent tooth is included in the

fee for the root canal.

Endodontic therapy (including treatment plan, clinical procedures,

and follow-up care)

GP - The fee for a root canal includes treatment radiograph images

and temporary restorations and all necessary diagnostic

procedures.

GP - Root canal therapy is only a covered benefit on permanent

teeth.

f,x D3310 endodontic therapy, anterior tooth (excluding final restoration)

f,x D3320 endodontic therapy, bicuspid tooth (excluding final restoration)

f,x D3330 endodontic therapy, molar (excluding final restoration)

A paste type root canal filling is not a benefit.

Palliative treatment in conjunction with root canal therapy by the

same provider is to be included in the fee for the root canal.

Unsuccessful attempts of endodontic treatment are not payable or

chargeable to the patient.

14

Retreatment of root canal therapy or apical surgery by the same

dentist/dental office within 24 month is considered part of the

original procedure. Incompletely filled root canals are not payable.

Root canal therapy is not a benefit in conjunction with

overdentures. Or extruded teeth to be restored for the purpose of

improving the occlusal plane.

Endodontic retreatment

GP - By report and predetermination is suggested if patient is not

in pain.

r,fx D3346 retreatment of previous root canal therapy - anterior

r,fx D3347 retreatment of previous root canal therapy - bicuspid

r,fx D3348 retreatment of previous root canal therapy – molar

Apexification / recalcification procedures

x D3351 apexification/recalcification – initial visit (apical closure / calcific

repair of perforations, root resorption, etc.)

Apexification is only allowable on permanent teeth with

incomplete root development or for repair of a perforation.

D3352 apexification/recalcification – interim medication replacement

D3353 apexification/recalcification - final visit (includes completed root

canal therapy - apical closure/calcific repair of perforations, root

resorption, etc.)

Apicoectomy/ periapical services

x D3410 apicoectomy - anterior

x D3421 apicoectomy - bicuspid (first root)

x D3425 apicoectomy - molar (first root)

x D3426 apicoectomy (each additional root)

fx D3430 retrograde filling per root

Retrograde filling includes all retrograde procedures per root.

x D3450 root amputation - per root

Root amputation performed in conjunction with an apicoectomy is

not a separate benefit.

15

Fee will be modified if done with periodontal surgery in the same

area.

D3460 endodontic endosseous implant

Not a covered benefit.

D3470 intentional reimplantation (including necessary splinting)

Intentional reimplantation is a specialized technique and therefore

is not covered.

Other endodontic procedures

D3910 surgical procedure for isolation of tooth with rubber dam

The fee for isolation of tooth with rubber dam is included in the

procedure performed.

x D3920 hemisection (including any root removal), not including root canal

therapy

A hemisection performed in conjunction with root removal or

apicoectomy is included in the fee for that service.

The fee will be modified if done with osseous surgery in the same

area.

D3950 canal preparation and fitting of performed dowel or post

Canal preparation and fitting of performed dowel or post is

included in the fee for the post or root canal.

D3999 unspecified endodontic procedure, by report

D4000 - D4999 V. PERIODONTICS

Surgical services (including usual postoperative services)

GP - Periodontal surgery includes routine post-operative care for 3

months following treatment.

GP - The fee for re-entry within three years of the original

periodontal surgery is a part of the fee for the original procedure

unless extraordinary circumstances are documented.

16

GP - Radiographs and Periodontal Chart are required

GP - Quadrant fees may be prorated according to the number of

teeth treated, based on a minimum of 4 teeth per quadrant. A

maximum of 4 quadrants will be allowed.

D4210 gingivectomy or gingivoplasty - four or more contiguous teeth or

tooth bounded spaces per quadrant

(perio charting and diagnosis are required).

r D4211 gingivectomy or gingivoplasty - one to three contiguous teeth or

tooth bounded spaces per quadrant

(by report is required).

Gingivectomy or gingivoplasty - per tooth is included in the fee for

the restorations done at the same time.

x D4240 gingival flap procedure, including root planing - four or more

contiguous teeth or tooth bounded spaces per quadrant

x D4241 gingival flap procedure, including root planing - one to three

contiguous teeth or tooth bounded spaces per quadrant

x D4245 apically positioned flap

x D4249 clinical crown lengthening - hard tissue

Crown lengthening is payable per site and not payable per tooth

when adjacent teeth are included. This procedure is a benefit only

when bone is removed. It is not payable if done on the same day as

the crown preparation.

x D4260 osseous surgery (including elevation of a full thickness flap and

closure) – four or more contiguous teeth or tooth bounded spaces

per quadrant

Osseous surgery includes the fee for the distal wedge. Limited to

once every 36 month.

x D4261 osseous surgery (including elevation of a full thickness flap and

closure) – one to three contiguous teeth or tooth bounded spaces

per quadrant

17

Osseous surgery includes the fee for the distal wedge. Limited to

once every 36 month.

r,x D4263 bone replacement graft-first site in quadrant

Covered only in specific group. See PPO table.

r,x D4264 bone replacement graft-each additional site in quadrant


r,x D4266 guided tissue regeneration- resorbable barier, per site


r,x D4267 guided tissue regeneration – nonresorbable barrier, per site

(includes membrane removal)


x D4270 pedicle soft tissue graft procedure

x D4273 subepithelial connective tissue graft procedures, per tooth

x D4274 distal or proximal wedge procedure (when not preformed in

conjunction with surgical procedures in the same anatomical area)

Included in the fee for other periodontal surgery.

x D4277 free soft tissue graft procedure (including donor site surgery), first

tooth or edentulous tooth position in graft

x D4278 free soft tissue graft procedure (including donor site surgery), each

additional contiguous tooth or edentulous tooth position in same

graft site

Non – Surgical Periodontal Services

D4320 provisional splinting-intracoronal

Splinting is not a covered benefit.

D4321 provisional splinting - extracoronal

x D4341 periodontal scailing and root planning- four or more teeth per

quadrant

18

x D4342 periodontal scailing and root planning - one to three teeth per

quadrant

The time limitation for prophylaxis is established by contract.

Additional prophylaxis are optional and may be charged to the

patient. 04910 is counted toward the contract limitation for

prophylaxis.

A prophylaxis done on the same date as a periodontal prophylaxis,

curettage, scaling or root planing is considered to be part of and

included in those procedures.

A maximum of 4 different quadrants of root planning are allowed

within 24 months.

Surgical curettage and root planing are considered components of a

single procedure. Payment is made for curettage.

Periodontal root planning, per quadrant, must be completed within

three months of the beginning of periodontal therapy. Radiographs

are required.

r,xD4355 full mouth debridement to enable comprehensive evaluation and

diagnosis

Allowed once in a lifetime. An adult prophylaxis is subject to

special consideration for a difficult prophylaxis, by report.

D4381 localized delivery of antimicrobial agents via controlled release

vehicle into diseased crevicular tissue, per tooth

Not covered

Other periodontal services

D4910 periodontal maintenance

Periodontal prophylaxis count toward the prophylaxis limitations.

Procedure 04910 includes the examination.

rD4999 unspecified periodontal procedures, by report.

D5000 - D5899 VI. PROSTHODONTICS (REMOVABLE)

19

GP - Any characterization, staining, overdentures or metal bases

are specialized techniques and an allowance will be made for a

conventional denture. Any additional fee is the patient’s

responsibility.

GP - Full or partial dentures includes any reline/rebase, adjustment

or repair required within 6 months of delivery; except in the case

of immediate denture, relines may be a benefit after 3 months.

GP - Prosthetics (removable) are subject to a 5 year limitation for

replacement.

Complete dentures (including routine post - delivery care)

x D5110 complete denture - maxillary

x D5120 complete denture - mandibular

x D5130 immediate denture - maxillary

x D5140 immediate denture - mandibular

GP - A fixed bridge and partial denture are not benefits in the

same arch. Benefit is limited to the allowance for a partial denture.

GP - Fixed bridges or removable cast partials are not a benefit for

patients under age 16. (Contract limitation)

GP - Partial dentures are subject to a 5 year limitation for

replacement.

GP - Valplast partials do not fix the description of codes 5211 thru

5281. An allowance will be made for a 5211 or 5212. Any

additional fee is the patients responsibility.

Partial Dentures (Including Routine Post – Delivery Care)

x D5211 maxillary partial denture- resin base (including any conventional

clasp, rest and teeth)

x D5212 mandibular partial denture-resin base (including any conventional

clasp, rest and teeth)

x D5213 maxillary partial denture - cast metal framework with resin denture

bases (including any conventional clasps, rests and teeth)

x D5214 mandibular partial denture - cast metal framework with resin

denture bases (including any conventional clasps, rests and teeth)

x D5281 removable unilateral partial denture-one piece cast metal

(including clasps and teeth)

Adjustments to dentures

20

GP - Full or partial dentures include any adjustment or repair

required within 6 months of delivery.

GP - Adjustments to dentures are limited to 2 adjustments per

denture per 12 months.

GP - Denture adjustments are covered in the basic level benefit.

D5410 adjust complete denture - maxillary

D5411 adjust complete denture - mandibular

D5421 adjust partial denture - maxillary

D5422 adjust partial denture – mandibular

Repairs to Complete Dentures

r D5510 repair broken complete denture base

r D5520 replace missing or broken teeth - complete denture (each tooth)

Repairs to partial dentures

GP - Fee for repair of a partial denture cannot exceed one-half of

the fee for a new appliance.

r D5610 repair resin denture base

r D5620 repair cast framework

r D5630 repair or replace broken clasp

r D5640 replace broken teeth-per tooth

r D5650 add tooth to existing partial denture

r D5660 add clasp to existing partial denture

Denture rebase procedures

GP - Rebase is a benefit once in 36 month period.

GP - Repair cast framework

GP - Rebase includes adjustments requires within 6 month of

delivery.

GP - Denture rebases are covered under the prosthodontic level.

D5710 rebase complete maxillary denture

D5711 rebase complete mandibular denture

21

D5720 rebase maxillary partial denture

D5721 rebase mandibular partial denture

Denture reline procedure

GP - Relines are benefits once in a 36 month period.

GP - Relines includes adjustments required within 6 months of

delivery

GP - Relines are covered under prosthodontic level

D5730 reline complete maxillary denture (chairside)

D5731 reline complete mandibular denture (chairside)

D5740 reline maxillary partial denture (chairside)

D5741 reline mandibular partial denture (chairside)

D5750 reline complete maxillary denture (laboratory)

D5751 reline complete mandibular denture (laboratory)

D5760 reline maxillary partial denture (laboratory)

D5761 reline mandibular partial denture (laboratory)

Interim Prostheesis

D5810 interim complete denture (maxillary)

D5811 interim complete denture (mandibular)

Temporary complete denture is not a benefit

r,x D5820 interim partial denture (maxillary)

r,x D5821 interim partial denture (mandibular)

Temporary partial-stayplate denture 05820 or 05821 is a benefit

only when replacing permanent anterior teeth during the healing

period.

Other Removable Prosthetic Services

D5850 tissue conditioning, maxillary

D5851 tissue conditioning, mandibular

Tissue conditioning, 05850 or 05851 is not a benefit if performed

on the same day the denture is delivered or a reline/rebase is

provided.

22

Tissue conditioning is not a benefit more than twice per denture

unit in 36 months.

r D5862 precision attachment, by report

A precision attachment is not a benefit. It is a specialized

technique.

r D5863 overdenture – complete maxillary, by report

r D5864 overdenture – partial maxillary, by report

r D5865 overdenture – complete mandibular, by report

r D5866 overdenture – partial mandibular, by report

Overdentures are considered a specialized technique. An allowance

will be made for a conventional denture.

r D5899 unspecified removable prosthodontic procedure, by report

D5900 - D5999 VII. MAXILLOFACIAL PROSTHETICS

GP - Maxillofacial prosthetics are not a covered benefit.

D5911 facial moulage (sectional)

D5912 facial moulage (complete)

D5913 nasal prosthesis

D5914 auricular prosthesis

D5915 orbital prosthesis

D5916 ocular prosthesis

D5919 facial prosthesis

D5922 nasal septal prosthesis

D5923 ocular prosthesis, interim

D5924 cranial prosthesis

D5925 facial augmentation implant prosthesis

D5926 nasal prosthesis, replacement

D5927 auricular prosthesis, replacement

D5928 orbital prosthesis, replacement

D5929 facial prosthesis, replacement

Intraoral prostheses-acquired defects

D5931 obturator prosthesis, surgical

D5932 obturator prosthesis, definitive

D5933 obturator prosthesis, modification

D5934 mandibular resection prosthesis with guide flange

D5935 mandibular resection prosthesis without guide flange

23

D5936 obturator prosthesis, interim

D5937 trismus appliance (not for TMD treatment)

Intraoral prostheses- congenital defects

D5951 feeding aid

D5952 speech aid prosthesis, pediatric

D5953 speech aid prosthesis, adult

D5954 palatal augmentation prosthesis

D5955 palatal lift prosthesis, definitive

D5958 palatal lift prosthesis, interim

D5959 palatal lift prosthesis, modification

D5960 speech aid prosthesis, modification

Treatment Prostheses

D5982 surgical stent

D5983 radiation carrier

D5984 radiation shield

D5985 radiation cone locator

D5986 fluoride gel carrier

D5987 commissure splint

D5988 surgical splint

r D5999 unspecified maxillofacial prosthesis, by report

D6000 - D6199 VII. IMPLANT SERVICES

GP - Implants services covered only in specific groups. See PPO special

group table.

Surgical Services

D6010 surgical placement of implant body: endosteal implant

D6040 surgical placement: eposteal implant

D6050 surgical placement: transosteal implant

r D6100 implant removal, by report

Implant Supported Prosthetics

D6055 connecting bar – implant supported or abutment supported

x D6058 abutment supported porcelain/ceramic crown


24

x D6059 abutment supported porcelain fused to metal crown (high noble

metal)


x D6061 abutment supported porcelain fused to metal crown (noble metal)


x D6062 abutment supported cast metal crown (high noble metal)


x D6064 abutment supported cast metal crown (noble metal)


x D6065 implant supported porcelain/ceramic crown


x D6066 implant supported porcelain fused to metal crown (titanium,

titanium alloy, high noble metal)


x D6067 implant supported metal crown (titanium, titanium alloy, high

noble metal)


x D6068 abutment supported retainer for porcelain/ceramic FPD


x D6069 abutment supported retainer for porcelain fused to metal FPD (high

noble metal)


x D6070 abutment supported retainer for porcelain fused to metal FPD

(predominantly base metal)


x D6071 abutment supported retainer for porcelain fused to metal FPD

(noble metal)

25


x D6072 abutment supported retainer for cast metal FPD (high noble metal)


x D6073 abutment supported retainer for cast metal FPD (predominantly

base metal)


x D6074 abutment supported retainer for cast metal FPD (noble metal)


x D6075 implant supported retainer for ceramic FPD


x D6076 implant supported retainer for porcelain fused to metal FPD

(titanium, titanium alloy, or high noble metal)


x D6077 implant supported retainer for cast metal FPD (titanium, titanium

alloy, or high noble metal)


Other Implant Services

D6080 implant maintenance procedures when prostheses are removed and

reinserted, including cleansing of prostheses and abutments

r D6090 repair implant supported prosthesis, by report

r D6095 repair implant abutment, by report

r D6199 unspecified implant procedure, by report

D6200 - D6999 IX. PROSTHODONTICS, fixed

GP - Full mouth or panorex is required

GP - Payment will be based on the number of pontics necessary

for the space, not to exceed the normal complement of teeth.

26

GP - A fixed bridge and partial denture are not benefits in the

same arch. Benefit is limited to the allowance for a partial denture.

GP - Fixed prosthodontics are not a benefit for children under 16

years of age.

GP- Porcelain and resin inlay bridges are not covered benefits.

GP - Prosthetics (fixed) are subject to a 5 year limitation for

replacement.

GP - Porcelain fused to metal crowns for posteriors to the second

bicuspid position are optional. An allowance will be made for the

appropriate cast crown, and the patient is responsible for the

additional cost.

Fixed partial denture pontics

x D6210 pontic - cast high noble metal

x D6211 pontic - cast predominantly base metal

x D6212 pontic - cast noble metal

x D6214 pontic – titanium


x D6240 pontic - porcelain fused to high noble metal

x D6241 pontic - porcelain fused to predominantly base metal

x D6242 pontic - porcelain fused to noble metal

x D6250 pontic - resin with high noble metal

x D6251 pontic - resin with predominantly base metal

x D6252 pontic - resin with noble metal

Fixed partial denture retainers-inlays/onlays

x D6545 retainer - cast metal for resin bonded fixed prosthesis

A three unit acid-etch bonded bridge is a benefit only for replacing

a single tooth. Cantilevered bridges with a bonded wing retainer in

combination with a conventional retainer or posterior acid etch

bonded bridges are not a covered benefits.

x D6604 inlay - cast predominantly base metal, two surfaces

x D6605 inlay - cast predominantly base metal, three or more surfaces

x D6606 inlay - cast noble metal, two surfaces


27

x D6607 inlay - cast noble metal, three or more surfaces


Fixed partial denture retainers- crowns

x D6720 crown - resin with high noble metal

x D6721 crown - resin with predominantly base metal

x D6722 crown - resin with noble metal

x D6750 crown - porcelain fused to high noble metal

x D6751 crown - porcelain fused to predominantly base metal

x D6752 crown - porcelain fused to noble metal

x D6780 crown - 3/4 cast high noble metal

x D6781 crown - 3/4 cast predominantly base metal


x D6782 crown - 3/4 cast noble metal


x D6790 crown - full cast high noble metal


x D6791 crown - full cast predominantly base metal


x D6792 crown - full cast noble metal

x D6794 crown – titanium


Other fixed partial denture services

D6920 connector bar

Not covered

r D6930 re-cement or re-bond fixed partial denture

Re - cementation or re – bond of a bridge by the same dental office

within 6 months of the seating date is part of the fee for the

original procedure.

28

Re - cementation or bond of a bridge is a benefit limited to once

per year.

D6940 stress breaker

Not covered, it is considered a specialized technique.

D6950 precision attachment

Not covered, it is consider a specialized technique.

GP - Cast post and cores, prefabricated posts and cores and crown

build-ups have the same limitations as 2950, 2952, 2954.

D6975 coping

Coping is considered a specialized technique and is not covered.

r,x D6980 fixed partial denture repair necessitated by restorative material

failure

Fee for repair of a fixed/partial denture cannot exceed one-half of

the fee for a new appliance.

r D6999 unspecified fixed prosthodontic procedure, by report.

D7000 - D7999 X. ORAL AND MAXILLOFACIAL SURGERY

GP - The fee for all oral and maxillofacial surgery includes routine

postoperative care.

GP - Extractions Includes local anesthesia, suturing, if needed, and

routine postoperative care.

GP - Unsuccessful attempts at extractions are not payable or


D7111 extraction, coronal remnants - deciduous tooth

D7140 extraction, erupted tooth or exposed root (elevation and/or forceps

removal)

GP - Impaction codes are based on anatomical position rather than

the surgical procedure necessary for removal.

29

GP - Unsuccessful attempts at extractions are not payable or


x D7210 surgical removal of erupted tooth requiring removal of bone and/or

sectioning of tooth, and including elevation of mucoperiosteal flap

if indicated

x D7220 removal of impacted tooth- soft tissue

Occlusal surface of tooth covered by soft tissue; requires

mucoperiosteal flap elevation.

x D7230 removal of impacted tooth - partially bony

Part of crown covered by bone; requires mucoperiosteal flap

elevation and bone removal.

x D7240 removal of impacted tooth - completely bony

Most or all of crown covered by bone; requires mucoperiosteal flap

elevation and bone removal.

x D7250 surgical removal of residual tooth roots (cutting procedure)

Includes cutting of soft tissue and bone, removal of tooth structure,

and closure.

Fee for root recovery is included in the fee for surgical extraction if

done by the same dentist/dental office.

Other surgical procedures

GP - All surgical procedures include routine postoperative care.

x D7260 oroantral fistula closure

r,x D7270 tooth reimplantation and/or stabilization of accidentally evulsed or

displaced tooth

Includes postoperative care and removal of splint.

D7272 tooth transplantation (includes reimplantation from one site to

another and splinting and/or stabilization)

Not Covered. It is considered a specialized technique.

x D7280 surgical access of an unerupted tooth

x D7283 placement of device to facilitate eruption of impacted tooth


30

x D7285 incisional biopsy of oral tissue-hard (bone, tooth)

r D7286 incisional biopsy of oral tissue-soft

Biopsy of oral tissue is included in the fee for other surgical

services in the same area. A pathological report must be included.

Biopsy of oral tissue is only payable for oral structures.

r,x D7290 surgical repositioning of teeth

Surgical repositioning of teeth is a benefit only if orthodontic

coverage is present.

r D7291 transseptal fiberotomy / supra crestal fiberotomy, by report

Transseptal fiberotomy is a benefit only if orthodontic coverage is

present.

Alveloplasty-surgical preparation of ridge

GP - Alveloplasty/ alveolectomy performed for less than five

adjacent tooth sockets is not elegible for benefits.

r,x D7310 alveoloplasty in conjunction with extractions - four or more teeth

or tooth spaces, per quadrant

Alveoloplasty is included in the fee for the surgical extractions.

r,x D7311 alveoloplasty in conjunction with extractions - one to three teeth or

tooth spaces, per quadrant


r D7320 alveoloplasty not in conjunction with extractions - four or more

teeth or tooth spaces, per quadrant

r D7321 alveoloplasty not in conjunction with extractions - one to three

teeth or tooth spaces, per quadrant


31

Vestibuloplasty

GP - All procedures are by report and subject to coverage under

medical insurance.

r D7340 vestibuloplasty - ridge extension (secondary epithelialization)

r D7350 vestibuloplasty - ridge extension (including soft tissue grafts,

muscle reattachments, revision of soft tissue attachment and

management of hypertrophied and hyperplastic tissue)

Surgical excision of soft tissue lesions

GP - All procedures are by report and subject to coverage under

medical insurance.

r D7410 excision of benign lesion up to 1.25 cm

r D7465 destruction of lesion(s) by physical or chemical method, by report


Surgical excision of intra – osseous lesions

GP - All procedures are by report and are subject to coverage

under medical insurance.

r D7440 excision of malignant tumor - lesion diameter up to 1.25 cm

r D7441 excision of malignant tumor - lesion diameter greater than 1.25 cm

r D7450 removal of benign odontogenic cyst or tumor - lesion diameter up

to 1.25 cm

r D7451 removal of benign odontogenic cyst or tumor - lesion diameter

greater than 1.25 cm

r D7460 removal of benign nonodontogenic cyst or tumor - lesion diameter

up to 1.25 cm

r D7461 removal of benign nonodontogenic cyst or tumor - lesion diameter

greater than 1.25 cm

32

Excision of bone tissue



D7490 radical resection of maxilla or mandible

r D7471 removal of lateral exostosis (maxilla or mandible)

r D7472 removal of torus palatinus


r D7473 removal of torus mandibularis


Surgical incision



r D7510 incision and drainage of abscess-intraoral soft tissue

Surgical incision is included in the fee for endodontics, extractions,

or other definitive service.

r D7520 incision and drainage of abscess-extraoral soft tissue

Incision and drainage of abscess-extraoral soft tissue is a benefit

only if dentally related infection is present.

r D7530 removal of foreign body from mucosa, skin, or subcutaneous

alveolar tissue

r D7540 removal of reaction producing foreign bodies, musculoskeletal

system

D7550 partial ostectomy / sequestrectomy for removal of non-vital bone

D7560 maxillary sinusotomy for removal of tooth fragment or foreign

body

Treatment of fractures-simple

33



r D7610 maxilla - open reduction (teeth immobilized if present)


r D7620 maxilla - closed reduction (teeth immobilized if present)


r D7630 mandible - open reduction (teeth immobilized if present)


r D7640 mandible - closed reduction (teeth immobilized if present)


r D7650 malar and / or zygomatic arch-open reduction


r D7660 malar and / or zygomatic arch-closed reduction


r D7670 alveolus closed reduction may include stabilization of teeth


D7680 facial bones - complicated reduction with fixation and multiple

surgical approaches

Treatment of fractures-compound



D7710 maxilla - open reduction

D7720 maxilla - closed reduction

D7730 mandible - open reduction

D7740 mandible - closed reduction

D7750 malar and / or zygomatic arch-open reduction

34

D7760 malar and / or zygomatic arch-closed reduction

D7770 alveolus - open reduction stabilization of teeth

D7780 facial bones - complicated reduction with fixation and multiple

surgical approaches

Reduction of dislocation and management of other temporomandibular joint

dysfunctions. Procedures which are an integral part of a primary procedure should not be

reported separately

GP - All procedures except D7880 and D7899 are not covered

D7810 open reduction of dislocation

D7820 closed reduction of dislocation

D7830 manipulation under anesthesia

D7840 condylectomy

D7850 surgical discectomy, with / without implant

D7852 disc repair

D7854 synovectomy

D7856 myotomy

D7858 joint reconstruction

D7860 arthrotomy

D7865 arthroplasty

D7870 arthrocentesis

D7872 arthroscopy - diagnosis, with or without biopsy

D7873 arthroscopy - surgical: lavage and lysis of adhesions

D7874 arthroscopy - surgical: disc repositioning and stabilization

D7875 arthroscopy - surgical: synovectomy

D7876 arthroscopy - surgical: discectomy

D7877 arthroscopy - surgical: debridement

r D7880 occlusal orthotic device, by report


r D7899 unspecified TMD therapy, by report


Repair of traumatic wounds

GP - Repair of traumatic wounds is limited to oral structures.

r D7910 suture of recent small wounds up to 5 cm

Complicated suturing (reconstruction requiring delicate handling of tissues and

wide undermining for meticulous closure)

GP - Complicated suturing is limited to oral structures.

35

r D7911 complicated suture - up to 5 cm

r D7912 complicated suture - greater than 5 cm

Other repair procedures

GP - All procedures except 07960, 07970 and 07971 are not

covered, the others are subject to coverage under medical

insurance.

D7920 skin grafts (identity defect covered, location and type of graft)

D7940 osteoplasty - for orthognathic deformities

D7941 osteotomy - mandibular rami

D7943 osteotomy - mandibular rami with bone graft; includes obtaining

the graft

D7944 osteotomy - segmented or subapical

D7945 osteotomy - body of mandible

D7946 LeFort I (maxilla - total)

D7947 LeFort I (maxilla - segmented)

D7948 LeFort II or LeFort III (osteoplasty of facial bones for midface

hypoplasia or retrusion) - without bone graft

D7949 LeFort II or LeFort III - with bone graft

D7950 osseous, osteoperiosteal, or cartilage graft of the mandible or

maxilla - autogenous or nonautogenous, by report

D7955 repair of maxillofacial soft and/or hard tissue defects

D7960 frenulectomy - also known as frenectomy or frenotomy - separate

procedure not incidental to another procedure

Frenulectomy is included in the fee for other surgical procedure (s)

in the area.

D7970 excision of hyperplastic tissue - per arch

Excision of hyperplastic tissue is included in the fee for other

surgical procedure (s) in the area.

D7971 excision of pericoronal gingiva

Excision of pericoronal gingival is included in the fee for other

surgical procedure (s) in the area.

D7980 sialolithotomy

D7981 excision of salivary gland, by report

D7982 sialodochoplasty

D7983 closure of salivary fistula

D7990 emergency tracheotomy

D7991 coronoidectomy

D7995 synthetic graft - mandible or facial bones, by report

36

D7996 implant - mandible for augmentation purposes (excluding alveolar

ridge), by report

D7999 unspecified oral surgery procedure, by report

D8000 - D8999 XI. ORTHODONTICS

GP - Pre-certification is required for orthodontic treatment.

GP - Extension of orthodontic treatment are not a covered benefits.

GP - Treatments terms will only be paid from 18 thru 36 months.

GP - Orthodontic benefits are limited to children of at least 6 years

of age, or up to contract limitations.

Limited orthodontic treatment

* D8010 limited orthodontic treatment of the primary dentition

* D8020 limited orthodontic treatment of the transitional dentition

* D8030 limited orthodontic treatment of the adolescent dentition

* D8040 limited orthodontic treatment of the adult dentition

Interceptive orthodontic treatment

* D8050 interceptive orthodontic treatment of the primary dentition

* D8060 interceptive orthodontic treatment of the transitional dentition

Comprehensive orthodontic

* D8070 comprehensive orthodontic treatment of the transitional dentition

* D8080 comprehensive orthodontic treatment of the adolescent dentition

* D8090 comprehensive orthodontic treatment of the adult dentition

Minor treatment to control harmful habits

* D8210 removable appliance therapy

* D8220 fixed appliance therapy

Other Orthodontic Services

37

*D8660 pre-orthodontic treatment examination to monitor growth and

development

* D8670 periodic orthodontic treatment visit (as part of contract)

* D8680 orthodontic retention (removal of appliances, construction and

placement of retainer(s)

* D8690 orthodontic treatment (alternative billing to a contract fee)

* D8691 repair of orthodontic appliance

* D8694 repair of fixed retainers, includes reattachment

r,* D8999 unspecified orthodontic procedure, by report

D9000 - D9999 XII. ADJUNCTIVE GENERAL SERVICES

Unclassified treatment

r D9110 palliative (emergency) treatment of dental pain-minor procedures

Palliative treatment is not a benefit when any other service is done

on the same date except limited radiographs and test necessary to

diagnose the emergency condition.

Emergency palliative treatment is payable on a per visit basis, once

on the same date. The diagnosis and all procedures necessary for

relief of pain are included.

Palliative treatment in conjunction with root canal therapy by the

same dentist is included in the fee for the root canal.

Documentation should be submitted with claims for this procedure.

If the procedure performed is a procedure with a specific code

established by the ADA and / or CDT, it will be processed

accordingly and not as a 9110.

Anesthesia

GP- All procedures are not covered except D9220.

D9210 local anesthesia not in conjunction with operative or surgical

procedures

D9211 regional block anesthesia

D9212 trigeminal division block anesthesia

38

D9215 local anesthesia in conjunction with operative or surgical

procedures

r D9220 deep sedation / general anesthesia - first 30 minutes

The fee for general anesthesia is a benefit only when administered

by a properly licensed dentist in a dental office in conjunction with

multiple impactions or surgery.

D9230 inhalation of nitrous oxide/analgesia, anxiolysis

Analgesia is not a covered benefit.

Professional consultation

r D9310 consultation - diagnostic service provided by dentist or physician

other than requesting dentist or physician

See D0160

Professional visits

D9410 house / extended care facility call

Not Covered

r D9420 hospital or ambulatory surgical center call


D9430 office visit for observation (during regularly schedule hours)-no

other services performed

Not Covered

D9440 office visit - after regularly schedule hours

Not Covered

Drugs

D9610 therapeutic parenteral drug, single administration

Not Covered

39

r D9630 other drugs and/or medicaments, by report


Miscellaneous Services

r D9910 application of desensitizing medicament

Application of desensitizing medicaments is not a covered benefit.

D9920 behavior management, by report

Not Covered

r D9930 treatment of complications (post-surgical) - unusual circumstances,

by report

Treatment of routine complications is not a covered benefit unless

performed by a dentist other than the treating dentist.

r D9940 occlusal guard, by report


D9941 fabrication of athletic mouthguard

Not Covered

D9950 occlusion analysis - mounted case

Not Covered

r D9951 occlusion adjustment - limited


r D9952 occlusion adjustment-complete


D9970 enamel microabrasion

Not Covered

r D9999 unspecified adjunctive procedure, by report.

40

ADA – CDT

Revised – 2015

x = a radiograph image must be included r = a report must ... · - dentures and partials date of...

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